Stroke Prevention in Atrial Fibrillation: Looking Forward

被引:68
作者
Katsanos, Aristeidis H. [1 ,2 ]
Kamel, Hooman [3 ,4 ]
Healey, Jeff S. [5 ]
Hart, Robert G. [1 ,2 ]
机构
[1] McMaster Univ, Div Neurol, Hamilton, ON, Canada
[2] Hamilton Hlth Sci, Populat Hlth Res Inst, Hamilton, ON, Canada
[3] Weill Cornell Med, Clin & Translat Neurosci Unit, Feil Family Brain & Mind Res Inst, New York, NY USA
[4] Weill Cornell Med, Dept Neurol, New York, NY USA
[5] McMaster Univ, Populat Hlth Res Inst, Div Cardiol, Hamilton, ON, Canada
基金
美国国家卫生研究院;
关键词
atrial fibrillation; clinical trial; prevention & control; stroke; ACUTE ISCHEMIC-STROKE; ORAL ANTICOAGULATION; UNDETERMINED SOURCE; EMBOLIC STROKE; ANTITHROMBOTIC THERAPY; SECONDARY PREVENTION; COGNITIVE FUNCTION; CATHETER ABLATION; APPENDAGE CLOSURE; RANDOMIZED-TRIAL;
D O I
10.1161/CIRCULATIONAHA.120.049768
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Nonvitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non-vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of nonvitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
引用
收藏
页码:2371 / 2388
页数:18
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